Whom to contact:

The review agent that rendered the adverse decision

Who can appeal:

You, your provider, or your authorized representative

What you can appeal:

Adverse decisions, which are decisions by a review agent not to certify a health care service.

When you can appeal:

After denial for coverage has been appealed through the 2nd level of the health plan’s internal process, you must file within 60 days from receipt of the 2nd level appeal denial.

What to send:

Notices of adverse decisions will contain instructions for how to initiate the next level of appeal.

What you must pay:

Half of the cost of the review. The cost depends on which external review agency is used. If the adverse decision is overturned, your payment will be refunded.

What will happen:

1. You will select the external review agency.
2. The review agent will provide information to the external appeals agency within 5 days of receiving the initial notification of appeal.
3. The external appeals agency will review the information and make a determination. The appeal will not be processed until the fee and all required documentation is received.

When you will get a decision:

Within 10 business days

In urgent situations:

In an emergency, an expedited appeal will be reviewed and decided by the external appeals agency within 2 days.